20th anniversary issue

Alternative and complementary approaches in psychiatry: beliefs versus evidence Pierre Schulz, MD; Vincent Hede, MD

Introduction

he power of human imagination has led our ancestorsT to consider the influence of celestial bodies, spirits, and gods on the horror of diseases and death. Over millennia, priests, shamans, sacred men, and medicine men helped their peers by predicting their While the legitimacy of medical treatments is more and fate and cure on the basis of various rituals, such as more questioned, one sees a paradoxical increase in examining animal intestines or ingesting diverse com- nonconventional approaches, notably so in psychiatry. pounds. The Jesuit Athanasius Kircher (1602-1680) Over time, approaches that were considered valuable wrote of interactions between planets, plants, and by the scientific community were found to be ineffi- animals, and he considered God as the central mag- cacious, while other approaches, labelled as alterna- net of all things. The physician Franz Mesmer (1734- tive or complementary, were finally discovered to be 1815) extended Kircher’s idea into application of the useful in a few indications. From this observation, we vital principle as a therapy for psychiatric symptoms propose to classify therapies as orthodox (scientifically for which there was then no therapy (Figure 1). In the validated) or heterodox (scientifically not validated). United States, members of the Fox family declared by To illustrate these two categories, we discuss the place, 1888 that their mediumnity was in fact a hoax, which the role, the interest, and also the potential risks of did not stop the appeal of exchanging messages with nonconventional approaches in the present practice of the dead; only later in the 20th century did spiritism fall psychiatry. into some disrepute. © 2018, AICH – Servier Group Dialogues Clin Neurosci. 2018;20:207-214. Frontiers between recognized treatments and char- latanism have long been a theme of discussion, and

Keywords: alternative and complementary medicine; evidence-based medicine; Address for correspondence: Dr Pierre Schulz, 4 boulevard de la Tour heterodox; orthodox; psychiatry 1205, Geneva, Switzerland

Author affiliations: Former Head, Unit of Clinical Psychopharmacology, Department of Mental Health and Psychiatry, Geneva University Hospi- tals, Geneva, Switzerland (Pierre Schulz); Mood Disorders Unit, Depart- ment of Mental Health and Psychiatry, Geneva University Hospitals, Ge- neva, Switzerland (Vincent Hede)

Copyright © 2018 AICH – Servier Group. All rights reserved 207 www.dialogues-cns.org 20th anniversary issue

Louis of Jaucourt (1704-1779) wrote about this in the to our proposed qualifiers, CAMs can be orthodox in Diderot and d’Alembert Encyclopedia: given indications: biofeedback, neurofeedback, hypno- The desire to live is a passion so natural and so strong it sis, virtual reality techniques, mindfulness relaxation, is not surprising that those who in health have little or no omega 3 fatty acids, etc, while previously conventional faith in the skillfulness of an empiric with secrets, appeal approaches have been given up (frontal lobotomy, insu- nonetheless to this false physician in grave and serious ill- lin coma, meprobamate), and many nowadays off-label nesses, the same as those who are drowning cling to the prescriptions can be seen as heterodox. smallest branch. They persuade themselves of having re- ceived aid, each time that skilled men did not have the Clinical illustration 1. This 45 year-old patient is in effrontery to promise them a certainty. ambulatory care because of severe depression. He had Nowadays, complementary and alternative medicines been doing clerical work for 15 years but lost this job (CAMs) are presented as safe, effective and affordable because of conflicts with his boss. Psychotherapy, anti- treatments, also for mental health problems. We discuss depressants, and augmentation treatment were without this category of approaches in mental care, excluding benefit. He consulted another medical doctor who or- from this paper the role of traditional treatments in dered tests measuring neurotransmitters and their me- countries with little medical staff, where other tradi- tabolites, amino acids, and immune globulins, and pre- tional healers take care of the burden of disorders. scribed unusual treatment such as micronutrition and hormones. This gave the patient a feeling of being well Definition taken care of, although his depression did not improve.

CAMs are diagnostic techniques and treatment prac- tices outside mainstream and standard health care. It is said that complementary approaches are added to stan- dard health care, while alternative ones are substitutes for it, a somewhat spurious non-operational nuance, be- cause adding an alternative approach to a conventional one would make it complementary by definition.Inte- grative medicine is the combination of standard health care with CAMs, either simultaneously or successively. Some CAMs can be a priori labeled as charlatanism, ie, as useless approaches sold by charismatic healers to vulnerable customers. We propose two qualifiers related to CAMs as well as to standard health care. We label as orthodox (from the Greek ortho meaning right or straight path and doxa meaning belief) those techniques that have adequately, ie, scientifically and rationally, been demonstrated to be efficacious and useful. The history of discoveries of orthodox methods starts with the first schools of medicine in the early Mediterranean world, even ear- Figure 1. Franz Mesmer’s tub according to a 1784 French engraving lier elsewhere. We label heterodox those techniques The tub (baquet) contained immersed bottles with magnetized wa- ter and iron fillings. Iron rods coming out of the tub were directed that have been demonstrated as useless for diagnosis towards body parts and harmonica music was played while the pa- (iridology, astrology, etc) or as equivalent to placebo for tients held hands. Mesmer, who had fled from Vienna to Paris, was treatment (homeopathy, prayer for others, etc) or for considered a genius by some and a charlatan by others. Eight mem- which there is no reason to hope for efficacy over that bers from the Académie de Médicine and the Académie des Sciences demonstrated that the tingling, trembling, tears, and even convul- of placebo (protection through crystals, auriculothera- sions observed in persons who knew they were being magnetized py, aura therapy, Ho’oponopono, etc). Some heterodox were absent when subjects were magnetized while being unaware approaches date back thousands of years. According of it.

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Practitioners of heterodox approaches have at- do not spend enough time with patients, conventional tempted to have their techniques accepted as orthodox, treatment is not well reimbursed, wellness is a higher for example orgone machines by Wilhelm Reich, primal goal than the mere decrease in symptoms, viewing a therapy by Arthur Janov, orthomolecular psychiatry by person as a whole leads to a more human society, mod- Carl Pfeiffer. Treatment of depression under halluci- ern science bridges with ancient wisdom, the normal nogens, psychoanalysis, narco-analysis, and psychosur- state of Mother Nature is health, CAMs and other het- gery shifted from being heterodox to orthodox, only erodox approaches generate hope. People are induced to be later considered again as heterodox or possibly into using CAMs by the fact that science education is so. Some approaches are difficult to label as either or- neglected, by the existence of national and internation- thodox or heterodox because of lack of clinical studies al conferences on CAMs, and by the lack of state regu- or because of the unusual aspect of the method: pet- lations and recommendations. assisted therapy, visual and acoustic brain stimulation Suggestion is another reason for choosing CAMs. It machines, fecal microbiote transplant in psychiatry, etc. leads to reassurance and empowerment of the client: the therapy will work because the CAM practitioner says Multiplicity of complementary and so, and because he or she indicates that it restores har- alternative medicines mony and balance within bodily and mental energies. This is often felt as psychologically more comfortable CAM techniques are many and can be classified as than a medicine driven by technology, even if centered mainly biologically based (phytotherapy, diets, mas- on the patient, with its probabilistic predictions based sage) or addressing the mind/body relations (relaxation, on the complexity of clinical status, familial medical his- techniques of energies balancing, therapeutic action at tory and paraclinical testing (epigenome, metabolome, a distance). Clients searching for relief from psycho- proteome, genome, etc) and, in psychiatry, neuropsy- logical suffering can use, to quote a partial alphabetical chological testing and neuroimaging. Even this knowl- list of CAMS, acupressure, acupuncture, animal-based edge does not suffice to build certainty and uncertainty therapy, anthroposophy, atlas repositioning, astrology, remains an arduous concept for patients and doctors to aura therapy, auriculotherapy, Ayurveda, bracelets and acknowledge.1 With CAMs, empowerment arises from medals, Coué method, cryogenic whole body therapy the ease of understanding simple causes and mecha- at minus 100°C, crystals and minerals, DNA healing nisms that are not mingled: energy channels (acupunc- over the phone, energy techniques based on auras or ture), toxic substances (detoxification), energy transfer chakras, essential oils, family constellation therapy, ho- (subtle bodies therapy), the same cures the same (ho- meopathy, massages, osteopathy, pendulum dowsing, meopathy), the state of internal organs is projected on reiki, relaxation, regression towards previous lives, sen- the ear, the feet, or the iris (auriculotherapy, foot mas- sory deprivation, special shoe soles, talking to angels, sage, iridology), the precise choice of the therapeutic touch therapy, urotherapy, etc. Within a given CAM substance (bioresonnance), etc. Some CAMs are said to category, one can obtain diverse effects: Saint Gabriel be efficacious for many, if not almost all, ailments, and incense helps with making the right decisions, while Pa- this totalizing approach is also reassuring. dre Pio incense decreases stress and anxiety. CAMs can be associated, for example in phyto-astrology or litho- Clinical illustration 2. This young man has just been chakra-numerology. diagnosed with bipolar II disorder. His psychiatrist did not propose a clear cause for the onset of the dis- Reasons for choosing CAMs order. A naturopath firmly explained the link between the symptoms and a family loss in the patient’s early Reasons put forward by persons who choose CAMs childhood. He offered a treatment based on herbs, in are many: natural treatments are better than chemical order to balance vital energy. ones, psychotropic medications are not systematically effective and induce side effects, pharmaceutical indus- Confirming the opinion of the majority2 is yet an- tries aim only at their own profit, physicians consider other reason to choose CAMs: one reads that homeop- functional symptoms as not being diseases, physicians athy is not superior to placebo, but people hear friends

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tell their success story of having benefited from it. Also, activation in humans. In summary, there are many some medical doctors become practitioners of CAMs. fundamental laboratory and too few clinical studies of CAMs, a regrettable situation, somewhat akin to that Clinical illustration 3. This 45-year-old woman with conventional therapies. These fundamental studies works as a surgeon in emergency and other hospital have, however, not yet established well-defined specific services. Because she felt a lack of human relations mechanisms by which a given CAM might act. with her patients, she decided to compensate for this by acquiring competence in the fields of acupuncture Efficacy and homeopathy, two CAMs that she then offered to hospitalized patients. Most CAMS have not been studied with placebo-con- trolled trials and selected randomized patients. When Personality, but also culture and education play such studies were done, the results were often equal to a role in the tendency towards belief in the paranor- placebos. Also, results about a given CAM were more mal: immigrants from Africa to Europe might combine positive in countries where it was already widely used.8 witchcraft and modern medicine knowledge to explain There are no studies on the associated administration their symptoms. All these reasons explain that anxious of CAMs, and few studies on the addition of CAMs to or depressed persons more often use CAMs than ortho- orthodox treatments. Some studies show astonishing dox treatments,3 and this has a high financial cost.4 results: while trials of praying for another person gener- ally showed no health effect9 or were criticized for their Mechanisms of action methodology,10 there is one study where North Ameri- cans who prayed for 199 Korean women undergoing in Several mechanisms of action are non-specific and vitro insemination doubled the fecundation rate, from common to all CAMs. The first one is suggestion,5 as- 26% to 50% of success.11 Sectarian religious groups are serted by the success of the French pharmacist Coué’s particularly prone to the diffusion of miracle cures, and method6 of conscious autosuggestion exemplified by his televangelists shout: “Depression, in the name of Jesus, sentence “every day, in every way, I am getting better go away… go away… demons go away.” The fact that and better,” by the number of self-help books, by the a CAM dates back hundreds of years is quoted as an benefits of placebo, and by the idea that doctors, profes- argument in favor of efficacy. Should black bile theory sors, or gurus (in the orthodox and heterodox domains still be accepted, just because Hippocrates described it? respectively) are powerful therapists. A second com- Or bloodletting, outside of cases of hemochromatosis? mon mechanism of action is giving the patient enough Simple protocols can test hypotheses underlying given time to feel listened to and understood as an individual. CAMs, for example by testing whether therapeutic A third mechanism common to several CAMs is the in- touch practitioners are capable of identifying whether duction of a restful state during the sessions. or not there is a person behind a thin opaque screen.12 There are potentially specific mechanisms of ac- CAMs’ efficacy is often alluded to on the basis of tion for some CAMs. The pharmacological effects and single cases. On the internet and/or other media, one modes of action of phytotherapy extracts or purified has access to many stories where a CAM practitioner substances have been recently studied using the same has interrupted years of a patient’s suffering from bipo- technologies as for pharmaceutical products discovery: lar disorder, depression, or schizophrenia just with a na- high-throughput screening, biomarkers identification turopathic treatment like homeopathy. These are indi- and system biology approach. Animal models of behav- cations either that the CAM prescribed was efficacious ioral and biochemical changes have also been used for for that person in that situation, or that the syndrome the study of CAMs’ mechanisms of action. As labora- improved spontaneously. Some CAMs are considered tory studies or animal studies are easier or less costly efficacious in the absence of controlled clinical trials: than clinical trials, there is an abundance of such proto- yoga, adequate diet, physical exercise might help in cas- cols on CAMs, for example the effect of acupuncture on es of depression. Thus, adding these CAMs to a conven- neuropeptide Y in the basolateral amygdala of mater- tional treatment might be useful. This does not apply nally separated rats,7 or its influence on brain networks to other CAMs such as micronutrition, homeopathy, or

210 Psychiatry alternative treatments - Schulz and Hede Dialogues in Clinical Neuroscience - Vol 20 . No. 3 . 2018 bioresonnance. Despite the lack of evidence for efficacy Clinical illustration 6. A 16-year-old boy was treated of many CAMs, a Beijing Declaration was adopted in for a delusional disorder, including the belief in his 2008 to call on WHO Member States and other stake- psychokinesis. His parents rejected medical help for holders to “take steps in order to integrate traditional weeks, because their own kinesiologist had assured medicine and CAMs into national health systems.” This them that a few persons are indeed endowed with the would, at least in part, represent accepting the use of ability of psychokinesis, of moving objects around impure placebos, ie, placebo not limited to a pharmaco- without touching them. logically inert substance. Finally, outside of the realm of CAMs, many non- The cost of treatment becomes a side effect when medical interventions are very beneficial, such as preven- inefficacious CAMs are expensive. There are also side tion of addictions, school bullying, child maltreatment, effects specific to given CAM. Acupuncture can lead to and others; studies on these primary prevention inter- hematoma pneumothorax, chylothorax, and perfora- ventions are of paramount relevance to mental health. tion of abdominal organs.14 Psychotic breakdowns or dissociative states can occur after dialogues with the Side effects dead, travel towards former lives, hypnosis, deep relax- ation through meditation and massages. Yoga can lead Many CAMs imply a form of magic world, with imme- to physical trauma. CAMs practitioners often have in- diate diagnoses, powerful transfers of energy, a chemi- sufficient training about efficacy and side effects. cally purified body, etc. These ideas go as far as believ- ing that entities from advanced planets take care of us, Clinical illustration 7. The mood swings of this 40-year- or that gurus survive without food by just being ex- old man with bipolar I disorder were stabilized with psy- posed to light. Thus, a first side effect of most CAMs is chotropic drugs. Despite good professional training, he a facilitation of paranormal beliefs, an alienation from had been unemployed for several years. In order to get a rational thinking. This side effect is of little medical or job, he asked a coach for assistance. The latter convinced psychiatric consequence for healthy people, but it can him of the uselessness of drugs, telling him that he should deter fragile or sick persons from the necessary ortho- only rely on himself. The patient kept seeing the coach dox diagnostic and treatment approaches. until his hospitalization for severe mania.

Clinical illustration 4. This woman was dying from Clinical illustration 8. This 30-year-old European pancreatic cancer and she only received homeopathic woman travels to India for an Ayurvedic treatment. A medicine from her medical doctor until her son asked severe acne breakout develops while there: she is told another doctor to prescribe opioids. that this is the sign of toxin removal. Back in Europe, she is proposed isotretinoin by a dermatologist, not a The dark side of suggestion is the nocebo effect, po- wise prescription because of her medical history of se- tent to the point of leading to voodoo deaths.13 Oppos- vere delusional depression. ing innocuous CAMs to the danger of orthodox medi- cations and treatment increases the nocebo effect of CAMs practitioners, aside from the caricatural be- these approaches. haviors illustrated in several of the above clinical illus- trations, also give wise advice such as getting enough Clinical illustration 5. This 50-year-old man refused to exercise, avoiding unhealthy food, taking time to medi- take an anxiolytic and inquiry into the reasons for his tate; this has few side effects, aside from some people refusal led to the discovery of his profound dislike of becoming obsessed by their cautious life habits. chemical medicine and to the fact that he had been non- compliant with the oral oncologic medication for weeks. Sources and quality of information

The goal of achieving harmony between mind and There exist few valuable sources of information outside body, between flows of energy, common to several of state-funded institutions such as the National Cen- CAMs, can present itself in non-realistic terms. ter for Complementary and Integrative Health (NC-

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CIH) in the United States, the National Health Service the above review seem quite optimistic, despite the (NHS) and the National Institute for Health and Care term “evidence-based” being in its title. Excellence (NICE) in Great Britain. Through the NC- Many journals for the general public participate in CIH readers have free internet access to the CAMs the diffusion of favorable opinions about CAMs. In or- they are interested in, the syndrome they wish to know der to adapt their message in a science-oriented culture, about, and how to treat it if they choose CAMs. The in- their journalists publish side-by-side articles dealing with formation is presented in a manner that assumes that real science (such as precise descriptions of neuroimag- the reader is capable of understanding clinical trials, ing results in psychiatric disorders) and articles on an- meta-analyses, and evidence-based medicine (EBM). gels having saved a child’s life. This mix of truthful and Collaborators of the Canadian CANMAT have made bizarre information blurs the distinction between peer- recommendations as to the use of CAMs in cases of reviewed information guaranteed by a self-corrective depression.15 The French Academy of Medicine recog- social system, and irrational belief in paranormal events, nizes acupuncture, osteopathy, tai-chi, and hypnosis as to which a proportion of CAMs refer. One finds mislead- being of possible value in given medical backgrounds, ing statements in the media that “the reality of mediums’ and homeopathy of absolutely no value. The Skep- interventions and powers are now proven by research tic’s Dictionary, available through the Internet, offers in university centers” or that “human consciousness is an extended list of critical analyses of CAMs that can explained by quantum physics.” The French astronomer help readers in their choices. The 2012 Flying Publisher Camille Flammarion (1842-1925) is a historical example Guide to Complementary and Alternative Medicine of a man of science having had irrational ideas: he as- Treatments in Psychiatry is of high quality and freely serted that the discovery of radio and telephone would accessible on the Internet, as are the many comments lead to confirming telepathy. A few well-known contem- from the Society for Science-Based Medicine pertain- porary scientists are fond of unproven ideas and they ing to CAMs regulations in the United States. publish books, host television shows, and have internet The Cochrane Collaboration reviews and the clini- portals. The internet offers information of dubious qual- cal trials of CAMs mentioned in PubMed are a valuable ity concerning both heterodox and orthodox approaches, source of information. Their content gives indications and this is the price for the otherwise justified concept of where CAMs could be useful, but mostly illustrates the information transparency. need for more studies, with the frequent occurrence of series of words such as “may be effective,” “larger more Clinical illustration 9. This 60-year-old man with a powered trials are needed,” “methodological flaws university education and training spends hours search- limiting definite conclusions,”“positive findings are ing the Internet about treatments for his mood disorder, reported… but there is currently insufficient research and participates in discussion on the Internet. He con- evidence for firm conclusions to be drawn,” etc. fronts his psychiatrist with all this information and asks Not all sources of information are of quality, even him to comment in detail on other medications and when of official nature. For example, the Internet portal why he should or should not try them. He thinks that Evidence Based Acupuncture mentions the 2003 World psychiatrists work mainly for pharmaceutical compa- Health Organization Report on Acupuncture, with the nies, and that there exist potentially useful but unknown 28 syndromes and disorders for which acupuncture was compounds outside mainstream prescriptions. considered proven through controlled trials to be an ef- fective treatment, including renal colic or malposition There are institutions dedicated to the control of of the fetus. Except depression, there was no psychiat- false and misleading advertisement, such as the Federal ric syndrome in this first list, but in the next list of 63 Trade Commission in the United States. In France, Mi- conditions where “therapeutic effect has been shown viludes works towards protecting citizens against sec- but for which further proof is needed,” one finds alco- tarian religious groups and debunking falsehoods in hol, cocaine, heroin, opium and tobacco dependence or CAMs. Readers who wish to read critical facts about detoxification, fibromyalgia, male sexual dysfunction, CAMs might consult the Internet portal of Professor premenstrual syndrome, schizophrenia, Tourette syn- Edzard Ernst (1948-), an emeritus professor of comple- drome, and vascular dementia. The conclusions from mentary medicine who became critical of CAMs.16

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All sources of information, and those on CAMs are Our recommendation to distinguish orthodox from no exception, confront readers with the uneasy task heterodox approaches in health care offers an opera- of evaluating the veracity of what is described. CAMs tional criterium for a classification that enables placing practitioners assume that patients are able to decide for each CAM along a continuum from clearly heterodox themselves. (This applies also to orthodox approaches to clearly orthodox, ie, an incentive towards a wider and to the promise of revolutionized medicine thanks use of the methodology of EBM for the evaluation to microtechniques and artificial intelligence).17 Once a of CAMS. Most of the work in view of the orthodox/ belief is established, the discovery of facts contradict- heterodox CAMs classification remains to be done, be- ing it (ie, knowledge rather than conviction) does not cause of the lack of relevant previous clinical research automatically lead to a new belief. This is true of decla- studies,20 the methodological issues with these studies, rations about the inefficacy of CAMs such as homeopa- and the lack of registration requirements and practice thy, as well as of acceptance of scientific discoveries.18 regulations for CAMs. It is necessary to identify CAMs for which there is compelling evidence of their useless- Conclusion ness, to disseminate these facts, and to inform the public in what cases they are paying for a method akin to a pla- Decades ago, lots of people considered CAMs as quack- cebo. With CAMs that might be somewhat superior to ery or fraud. This has now changed and the present dif- placebo, studies should address the questions of num- fusion of CAMs, with hundreds of methods and thou- bers and frequency of sessions, role of the experience of sands of practitioners in occidental countries, is neither the therapist, relative efficacy towards conventional ap- a sufficient nor a satisfactory argument to accept CAMs proaches, and consequences of associating CAMs with as a regular approach in treating psychiatric syndromes, conventional treatments. despite the empathy and the good intentions of many The task and challenge within the coming decade CAMs practitioners to alleviate human suffering. should be to draw frontiers between acceptable CAMs There are four major explanations why CAMs are and charlatanism, ie, to clearly differentiate truly inef- more largely used than justified by the controversies ficacious CAMs from the few that have, or might have, about their clinical efficacy. First, appreciation of occult useful therapeutic or preventive effects at least slightly sciences and magical ideas isn’t limited to the dark ages above placebo effects. Moreover, studies should be set of sorcery: it also represents an appealing option in times up to evaluate the best modalities for the transfer of when society is felt to be dominated by science and rea- objective information about CAMs, to explore how son, and paralogical thinking might presently be among patients understand EBM when their medical doc- the substitutes for the decrease in traditional religios- tor prescribes homeopathy, when the insurance reim- ity. Second, practicing CAMs is a developing means of burses this prescription, and when CAMs practitioners financial gains. The Internet has facilitated these gains by describe their treatments within simplistic overarching offering greater access to consumers, and CAMs consul- mechanisms. tations by telephone are billed or offered after receipt of On the condition that these different categories of a check. Third, some members of the medical profession, studies could be carried out, better state regulations as even within university hospitals, endorse CAMs. Patients to CAMs teaching, certification, and practice might be in given oncology units systematically receive hypnosis set up. In short, the requirements of EBM should be ap- to decrease their anxiety and depression, or the phone plied to CAMs’ evaluation. All this will be arduous, be- number of the person who will “make the secret,” ie, say cause of financial interests linked to CAMs and because special incantations that will prevent side effects of onco- of the not too fashionable, to say the least, promotion of logic treatments. In fact, patients prefer hospitals where reasonable doubt in the search for veracity. o CAMs are also offered.19 A fourth reason for the diffu- sion of CAMs is the limitation of efficacy in heterodox Disclosure/Acknowledgments: The authors have no conflicts of interest approaches in psychiatry and other specialties. to declare.

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REFERENCES 11. Cha KY, Wirth DP. Does prayer influence the success of in vitro fertil- ization-embryo transfer? Report of a masked, randomized trial. J Reprod 1. Bhise V, Rajan SS, Sittig DF, et al. Defining and measuring diagnostic uncer- Med. 2001;46(9):781-787. tainty in medicine: a systematic review. J Gen Intern Med. 2017;33(1)103-115. 12. Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. 2. Asch SE. Opinion and social pressure. Scientific American. 1955;193(5):31- JAMA. 1998;279(13):1005-1010. 35. 13. Gomez EA. Voodoo and sudden death: The effects of expectations on 3. Kessler RC, Soukup J, Davis RB, et al. The use of complementary and health. Transcultural Psychiatry Res Rev. 1982;19(2):75-92. alternative therapies to treat anxiety and depression in the United States. 14. Zhang J, Shang H, Gao X, Ernst E. Acupuncture-related adverse Am J Psychiatry. 2001;158(2):289-294. events: a systematic review of the Chinese literature. Bull World Health Or- 4. Purohit MP, Zafonte RD, Sherman LM, et al. Neuropsychiatric symptoms gan. 2010;88(12):915-921. and expenditure on complementary and alternative medicine. J Clin Psy- 15. Ravindran AV, Balneaves LG, Faulkner G, et al. Canadian Network for chiatry. 2015;76(7):e870-e876. Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for 5. Baudoin C. Suggestion and Autosuggestion. New York, NY: Dodd, Mead, the Management of Adults with Major Depressive Disorder: Section 5. and Co;1922. First published in French in 1920. Complementary and Alternative Medicine Treatments. Can J Psychiatry. 6. Coué E. Self Mastery Through Conscious Autosuggestion., New York, NY: 2016;61(9):576-87. American Library Service; 1922. First published in French in 1920. 16. Sinhh S, Ernst E. Trick or Treatment. Alternative Medicine on Trial., Lon- 7. Park HJ, Chae Y, Jang J, Shim I, Lee H, Lim S. The effect of acupuncture don, UK: Bantam Press;2008. on anxiety and neuropeptide Y expression in the basolateral amygdala of maternally separated rats. Neurosic Lett. 2005;377(3):179-184. 17. Topol E. The Patient Will See You Now. The Future of Medicine Is in Your 8. Vickers A, Goyal N, Harland R, et al. Do certain countries produce only Hands. New York, NY: Basic Books;2015. positive results? A systematic review of controlled trials. Control Clin Trials. 18. Kuhn TS. The Structure of Scientific Revolutions. Chicago, IL; University of 1998;19(2):159-166. Chicago Press;1962. 9. Radin J, Schlitz M, Baur C. Distant healing intention therapies: an over- 19. Carruzzo P, Graz B, Rodondi PY, Michaud PA. Offer and use of com- view of the scientific evidence. Glob Adv Health Med. 2015; (suppl):67-71. plementary and alternative medicine in hospitals of the French-speaking 10. Andrade C, Radhakrishnan R. Prayer and healing: a medical and sci- part of Switzerland. Swiss Med Wkly. 2013;143:w13756. entific perspective on randomized controlled trials.Indian J Psychiatry. 20. Gorski DH, Novella SP. Clinical trials of integrative medicine: testing 2009;51(4):247-253. whether magic works? Trends Mol Med. 2014;20(9):473-476.

214 Aproximaciones alternativas y complementarias Approches alternatives et complémentaires en en psiquiatría : creencias versus evidencia psychiatrie : croyances et preuves

Si bien la legitimidad de los tratamientos médicos se Tandis que la légitimité des traitements médicaux est de cuestiona cada vez más, se observa un aumento para- plus en plus mise en question, on constate une augmenta- dójico en las aproximaciones no convencionales, espe- tion paradoxale des approches non conventionnelles, no- cialmente en la psiquiatría. Con el tiempo, se descubrió tamment en psychiatrie. Avec le temps, des approches qui que las aproximaciones que la comunidad científica con- étaient considérées de valeur par la communauté scienti- sideraba valiosas eran ineficaces, mientras que otros en- fique se sont révélées inefficaces, tandis que d’autres, éti- foques, etiquetados como alternativos o complementa- quetées comme alternatives ou complémentaires, ont été rios, se descubrieron finalmente como útiles en algunas décrites comme efficaces dans quelques indications. À par- indicaciones. A partir de esta observación, se propone tir de cette observation, nous proposons de classer les trai- clasificar las terapias como ortodoxas (validadas científi- tements soit comme orthodoxes (validés scientifiquement) camente) o heterodoxas (no validadas científicamente). soit comme hétérodoxes (non validés scientifiquement). Para ilustrar estas dos categorías, se discute el lugar, el Pour illustrer ces deux catégories, nous commentons la papel, el interés y también los riesgos potenciales de las place, le rôle, l’intérêt et aussi les risques potentiels des ap- aproximaciones no convencionales en la práctica actual proches non conventionnelles dans la pratique actuelle de de la psiquiatría. la psychiatrie.